'The case of William Sizer is one of such painful interest as to require to be noticed'. 1

Transcription

1 'The case of William Sizer is one of such painful interest as to require to be noticed'. 1 My attention was first drawn to the case of William Sizer by an article in The Asylum Journal about an inquest conducted in relation to his death while a patient in the Norfolk County Asylum. 2 The matter is briefly mentioned in Cherry. 3 Dramatis Personae William Sizer was born in the parish of Wymondham in January 1820; he was baptised in the church of St Mary and St Thomas on 13 February. His parents were William Sizer, butcher, and Hannah Sizer (nee Wilkinson). 4 Mrs Sizer Norfolk County Lunatic Asylum Ebenezer Owen: Superintendent Edward Casson: Resident Medical Officer G W W Firth: Visiting Medical Officer George Wilkinson, Thomas Cook 5 : attendants having care of Sizer's ward Samuel Thomas Bell: night attendant when Sizer was purported to have suffered the injuries that caused his death Robert Fisher, John Ellis, Ebenezer Giles: other attendants examined during inquiry Towler Upcraft, William Vincent and John Catchpole: patients examined during inquiry Committee of Visiting Justices Rev T J Blofeld: Chairman Rev Charles Wodehouse: Visiting Justice (October 1854) Richard Ward: Visiting Justice (November 1854) Commissioners in Lunacy (conducting the investigation on 30 October 1854) Dr J R Hume: medical commissioner Mr B W Proctor: legal commissioner Others Mr Pilgrim: Coroner David Penrice: acting Medical Officer before Casson took up his duties (witness at inquest) Soldier of the Queen 6 On 27 January 1838, in Norwich, Sizer enlisted into the 77th (East Middlesex) Regiment of foot. At some point he would have joined the regiment in the Mediterranean; the 1841 census records him being in Malta but the regiment also served in Corfu at this time. In early 1843 the regiment was transferred to Jamaica where it remained for almost three years. In 1844 William Sizer was 1 Superintendent's Report, Annual Report for 1854 (SAH28). 2 The Asylum Journal of Mental Science: Vol I: nos 1-14, pp Cherry p64. 4 On his baptismal certificate the family name is spelt Sizar. As Sizer is used on all other occasions I have used that version throughout. Possibly he became 'Sizer' upon enlistment and his name was transcribed incorrectly. However, his father's name is spelt 'Syther' on his marriage certificate (19 January 1819)! ( 5 Spelling varies: either Cook or Cooke. 6 The details for Sizer's military career are taken from Saunder's Newsletter, Sizer's Notice of Discharge and Blaxland.

2 promoted to sergeant and the next year he received 'one distinguishing mark and good conduct pay of one penny per day' (!). January 1846 saw the regiment move to 'the rigours of Nova Scotia in the grip of winter'; a dramatic change from the Caribbean. Following service in 'the heart of Canada' the 77th transferred back to the United Kingdom in Following several changes of base (Portsmouth, Newport then Glasgow), in early 1854, the regiment was warned for active service in what was to become the Crimean War. It is unlikely that William Sizer saw combat himself as, between 1815 and 1854, 'few excitements enlivened the service of the 77th' although the regiment had had to contend with 'some violent riots' in Canada in the 1840s. Newspaper reports indicate that Sizer had not left with the main regiment in 1854 but had remained in the UK with the depot. In any case, as of 15 July 1854, his 'current attack' had been of three months' duration, ie, it had began approximately in mid April On 2 June 1854, at Parkhurst, Isle of Wight, a regimental board found 1120 Sergeant William Sizer 'unfit for further service' and proposed his discharge from the army. His reckonable service up to this date was 16 years and 127 days and his general character was rated 'very good'. From the Isle of Wight he was transferred to Chatham Hospital with other invalids. Saunders Newsletter noted that Sergeant Sizer was 'insane' and that 'for the last six weeks the poor fellow had been gradually getting worse'. After a brief stay in Chatham Hospital, Sizer returned to Wymondham as an out-pensioner on a permanent pension of one shilling a day. 8 Sizer resided, with his wife, at the home of his widowed aunt. Into the Asylum While at Chatham Hospital, his wife had reported that Sizer had experienced delusions that he was extremely wealthy and that he was the 'Admiral of the British Fleet'. He was also constantly singing and dancing. This singing and dancing continued at home and it was noted by an examining physician on 15 July 1854 that the dancing was in time to a clock. On that day Sizer was assessed to be of 'unsound mind' but was considered neither suicidal nor a threat to others. An order was made for his admission into Norfolk County Asylum where he was immediately taken. 9 Unfortunately there is no other information regarding Sizer in the asylum Case Book. Other than his name, age, marital status and former occupation, there is no entry until the day after his death. In this he is described as 'talkative and troublesome'. 10 The Annual Report for 1854 states that William Sizer was 'a patient whose mental condition was that of almost complete dementia'. 11 However, all witnesses who subsequently gave evidence in the matter agreed that he was 'very noisy and dirty but harmless'. He was never aggressive although he was given a black-eye by another patient a 7 Reception Order dated 15 July 1854 (SAH168/2). 8 From 1692 to 1955 all Army Pensions were administered and paid from the Royal Hospital Chelsea. In-Pensioners were those who surrendered their pension and lived in the hospital. Out-Pensioners were those who lived 'out' and received their pension from agents around the country. Sizer appears to have been granted the pension for an illness which was not the result of military duties. The standard pension, for sergeants for invalidity incurred as a result of service, was up to three shillings a day. (Skelly pp205-11) 9 Reception Order dated 15 July 1854 (SAH168/2). 10 Case Book ( ) (SAH261). A perusal of the first part of the Case Book indicates that this lack of information was not unusual, although this is a clear contravention of: Order as to the Case Book (8 & 9 Vict c100, s60); a copy of which is even pasted into the front of the book. Most patients do not appear to have admission entries and several have entries written after their death/discharge; one patient was admitted in 1847 but had no entry until 1853! Notwithstanding the chaotic nature of the Case Book and the failure to follow regulations, the Case Book has been 'signed off' by Commissioners in Lunacy on May 1853, September 1853, 30 October 1854 (!), October 1857 and May Annual Report for 1854 (SAH28).

3 month previous to his death. Initially he was assigned to a ward but later he slept in a room by himself although this appeared to be routinely locked at night. 12 On the night of Tuesday 17 October, Thomas Cook helped Sizer get undressed and into bed. At this time, Sizer was able to lift his arms to remove his clothes and 'he shewed no signs of pain'. Cook later recollected that he had briefly left Sizer alone in his room that afternoon and that on his return, 'he was very quiet'. During the night, Samuel Bell, the night attendant, and Robert Fisher, another attendant, entered Sizer's cell. Sizer 'said nothing, but merely mumbled as usual. Bell told him to keep quiet' and then replaced Sizer's shirt which had come off. Bell remembered that Sizer had said, 'What are you doing to me?' and from this thought that he had hurt him. Bell did not include this latter point in his statement. The next morning, George Wilkinson went into Sizer's cell to get him up. Sizer refused to get out of bed saying he was unwell. Wilkinson noticed a 'sore' on Sizer's side and informed the superintendent, Ebenezer Owen, who was just leaving for Norwich. Wilkinson was instructed to inform the resident medical officer, Edward Casson. Casson, who was informed at a about quarter to eight, attended Sizer and reported 'a large swelling on the right side of the chest... which was red...not from bruising, but from inflammation of the skin, and distinctly fluctuating'. An abscess was diagnosed and a poultice was applied. Cook stated that Sizer appeared unconcerned; on the application of the poultice, he had laughed and said he 'should like to eat the poultice'. Sizer remained in his room the rest of Wednesday. 'He had meat and beer for his dinner, and bread, cheese and beer for his supper. 'Unusually', (but not surprisingly), 'he did not eat the whole of it'. He also had some beef tea. His appetite was usually good. Owen visited Sizer early the next day (Thursday), having returned late the previous evening. 'About 12 o'clock', Casson came to Owen and reported that the injury was far more serious than at first thought. Owen accompanied Casson back to Sizer's cell. Some 'crepitation' 13 had been felt and upon further examination, it was discovered that several ribs had been fractured. Owen himself heard a 'grating sound'. Sizer was moved to the infirmary, having to be carried by the infirmary attendant, Ebenezer Giles. The lower part of Sizer's chest was then fixed by 'some long straps of plaister'. On Friday afternoon (20 October) a further examination by both Casson and the visiting medical officer, G WW Firth, discovered that Sizer's breastbone was also fractured; 'the patient's breathing was now much embarrassed, and unfavourable opinion was come to as to his recovery'. 'Some further circular bandages were applied to the whole chest'.that evening, Owen and both medical officers began 'a strict enquiry' among the attendants. 'We had several of them before us, questioned them very closely, but failed to elicit anything that would throw the least light on this, as yet very mysterious case'. Unfortunately, Sizer himself, was not in a 'state of mind' to assist the investigation. On Saturday, Owen 'spent the day 'occupied in questioning patients and staff 'but could not make anything out'. That evening he reported the matter to the Rev Charles Wodehouse, the visiting justice for the month. Next day, at 2pm, Wodehouse attended a further examination of Sizer by Firth. Firth considered Sizer's condition to be 'hopeless'. Again, no 'rational discourse' could be obtained from Sizer as to the cause of his injuries. During the course of the day, Mrs Sizer visited her husband. Further lengthy inquiries of the attendants by Wodehouse were again fruitless. Sizer's condition must then have deteriorated further for Owen sent two men to collect Mrs Sizer. 12 The story of William Sizer's last days has been taken from the various records in the Norfolk Record Office (see Bibliography) and the Norwich Mercury (28/10, 02/12/1854 and 10/01/1855). 13 to make a rattling or crackling sound.

4 She arrived and was with her husband when he died on Monday morning at 12 minutes past four. The death was reported to the coroner who arranged an inquest at the asylum for 1pm the same day. 'There is some mystery in the case' 14 Prior to the inquest, the two medical officers conducted a post mortem. The cause of death was given as 'purulent inflammation caused by fractured ribs'. Firth concluded that the injury on the chest 'must have been done with great violence' and thought that it could not have been done more than 10 or 12 days before (Casson thought 8 or 10 days) but, 'I think if Sizer received the injury on Tuesday, the appearance I discovered today might appear; but I think he received the injury before this time'. While Sizer would have been able to get back into bed as usual he would have been unable to make any 'quick movements'. The jury assembled at the asylum at the due time and the taking of evidence took about 4 hours. Evidence was given by Owen, Firth, Casson, David Penrice, Wodehouse, Wilkinson and Cook. No witness felt able to say how Sizer's injuries had occurred although Wilkinson's additional evidence perhaps suggested a cause. Wilkinson recollected, and Cook remembered him telling him, that in September, Sizer had upended his bed so that it lay sideways against the door of his cell. Sizer himself was standing on the floor near it, being very noisy and clapping his hands. Wilkinson had told him to be quiet and he had subdued. On his own initiative, Wilkinson had then removed the bedstead and Sizer had laid down on the bed; there had been no indication that Sizer had sustained an injury at this time. Presumably the bedstead had been returned at some point as its absence is not noted in events from 17 October. The coroner summed up the evidence and after a short deliberation the jury brought in a verdict: that William Sizer 'died from the effect of a serious injury he received, but how or by what means the same was inflicted, there is no evidence to prove; and the jury consider that there is some mystery in the case'. Owen noted in his journal, 'notwithstanding the 'denials persisted in by all the attendants as to their entire ignorance of how Sizer came by his injuries, I have all along felt convinced that the particulars of this dreadful case must be known to some of them. As yet, however, it would be impossible to point out with any degree of certainty the parties implicated'. 15 Both the Norfolk News and the Norfolk Chronicle remarked that Wodehouse 'appeared most anxious to have the real facts of the case ascertained'. 16 The Commissioners in Lunacy William Sizer was buried in the burial ground of the asylum on Thursday 26 October On that day, and it would be nice to think that he had attended Sizer's funeral, Wodehouse 'visited every part of the asylum' and found 'everything in good order'. The Commissioners in Lunacy were informed of Sizer's death and copies of the evidence given at the inquest were sent to them Wodehouse also confirmed that he had spoken about the case to the Chief Constable of Norfolk but nothing else appears to have resulted from that meeting Inquest verdict [Superintendent's Report, Annual Report for 1854 (SAH28), Norwich Mercury 28/10/1854]. 15 Superintendent's Journal ( ) (SAH129). 16 Norfolk News (28/10/1854), Norfolk Chronicle (28/10/1854). 17 Register of Burials ( ) (SAH232), The cost of the coffin, shroud, burial fees and bearers came to just over a pound. [Annual Report for 1854 (SAH28)]. 18 Visiting Justices' Report Book ( ) (SAH138).

5 On Monday, two Commissioners in Lunacy ( Dr J R Hume and Mr B W Proctor) descended upon the asylum for the purpose of investigating the case; the Chairman of the Committee of Visitors and Wodehouse were also present. 19 After an initial meeting with Owen and Casson, the commissioners visited Sizer's cell and considered the hypothesis that Sizer may have caused the injury himself by overturning the bedstead. Although the heavy wooden bedstead could have caused the injuries sustained by Sizer, the cell was too small to have allowed the full weight of the bedstead to have fallen on him. In any case, on the morning that the accident (in September) was discovered he had been 'lying quietly on his bed' and under the bedclothes; 'a circumstance in the highest degree improbable, if he had caused the bedstead to fall... in such a manner as to occasion so serious injury as that which he received'. In a 'very strict examination' of the attendants, the commissioners were able to elicit 'many fresh points in the evidence' but testimony given in some instants was conflicting in the extreme. Formal statements were taken from Wilkinson, Cook, Bell, Fisher, Giles and John Ellis. In addition to the attendants, the commissioners also spoke with three patients 'but could learn little or nothing from them on which to rely'. One of the patients, John Catchpole, claimed that he had seen Wilkinson and Cook 'hit Sizer once or twice, but not much, not violently'. Notwithstanding their 'very strict examination', the commissioners also found time to conduct a routine inspection of the asylum, the result of which was duly entered into the report book. Nothing referring to the Sizer case was entered into this book. 20 The commissioners then departed to complete their 'Special Report'. The next day at a regular meeting of the Committee of Visitors, Wilkinson, Cook and Bell were dismissed, although 'with the distinct understanding', that should any of them be 'relieved from the suspicion now resting upon them', he would be reinstated. The grounds for dismissal of the former two were that 'they ought to have known how injuries occurred'; for Bell, 'for prevarication in several points of statement'. All three left that evening, 'each having been paid the wages due to him up to this time'. 21 The medical officers considered that it was 'unfortunate' that no evidence had been taken from them by the commissioners; they were requested to complete their own report by the committee. The subsequent medical report incorporated the results of the post mortem which included: 'sternum was transversely fractured between the 2nd and 3rd ribs...four ribs were broken on each side. 'The opposite ends of the fractured surfaces were hollowed out by friction upon each other; the marrow and soft bony matter in their centre being gouged away, and the hard bone of their circumference remaining as sharp projecting edges. On the right side of the chest was a large circumscribed abscess of the pleura, communicating through the fractures with the external abscess above mentioned'. In the light of these findings the medical officers continued to insist that the injuries were sustained prior to the night of 17 October. On 19 November 1854, Owen received a copy of the 'Special Report' and copies of evidence taken by the commissioners. Copies were hand-delivered by Owen to the Chairman of the committee and Richard Ward, the new visitor for the month. The 'Special Report' and the completed Medical Officers' report were entered into the minutes of the next committee meeting (28 November) and 19 Information for the commissioners' investigation is taken from the Superintendent's Journal ( ) (SAH129) and the Norwich Mercury (02/12/1854) 20 Reports of Commissioners in Lunacy ( ) (SAH141) 21 Superintendent's Journal ( ) (SAH129), Annual Report for 1854 (SAH28), Clerk's Letter Book ( )(SAH38)

6 the clerk was instructed to send copies of both reports and evidence taken by the commissioners to the local newspapers for publication. The 'Special Report' concluded that the injuries to Sizer were inflicted during the night of Tuesday 17 October and that 'they were not self-inflicted nor accidental, nor inflicted by the falling of the bedstead'. There was insufficient evidence to determine 'whether the injuries...were inflicted by Bell and Fisher, or by Bell alone, or by any other person having access to the bedroom'. However, there was no evidence that anyone other than Bell and Fisher had entered Sizer's cell during Tuesday night, and it was remarked 'that their several statements are so contradictory to each other as to lead to the necessary inference that one or both of them wilfully misrepresented the facts'. In a reply to the commissioners (dated 2 December 1854) the Committee of Visitors acknowledged receipt of the Special Report and stated that Fisher had been retained in service 'as his statement relative to the transaction has been consistent throughout', whereas Bell's evidence had been contradictory. 'The various investigations...have failed to elicit any cause of these injuries'. 22 The Commission of Lunacy's response (dated 22 December) was frank and to the point. The medical members of the commission were unanimous in rejecting the medical officers' claim that the injuries had been sustained previous to 17 October. Given the 'severe and extreme injuries', it was 'to the highest degree improbable' that Sizer had been able to undress and go to bed without some expression of pain. The Commission trusted that further enquiries would be undertaken of all persons in the asylum, and that counsel would be instructed to assist.. In particular, Fisher should be 'subjected to further strict examination'. Then the gloves came off: 'the commissioners are clearly of the opinion that the case ought not to remain in its present unsatisfactory state, and they hope that the justices will adopt such a course as will prevent the necessity of any further interference on the part of this board'. This shot across the bows was considered at the next committee meeting on 26 December. Unfortunately, the minutes concentrate on noting results rather than recording any discussions. A reply to the Commission and the annual report for the year were agreed. The Committee, in its reply (dated 28 December), claimed to have already "used every means to elicit the truth" and it considered that the dismissal of the three attendants had been the 'only practicable course which presented itself'; a course, indeed, in which both Dr Hume and Mr Proctor had concurred. In the event that the Commission could identify any further avenue of inquiry, the Committee would give it its 'best assistance'. Regretfully, the patients sleeping next to Sizer's room 'were of the epileptic and idiotic class' and they had proved 'utterly 23 incapable of giving any information'. Of the four patients mentioned in the investigation, the three who are recorded as giving evidence, and the patient who had given Sizer a black-eye, two were discharged the day after the commissioners' inquiry and one died just before the Quarter Sessions! The three 'witnesses' were diagnosed with melancholia, mania and destructive idiocy respectively; John Catchpole was recorded as being of 'good bodily health but very lazy' and he did not 'answer questions coherently'. 24 At the Norfolk County Sessions, Blofeld stated that he believed that 'every step that could be taken to elicit the truth in the matter' had been taken. The Committee of Visitors was re-appointed and they brought the matter to a close Annual Reports (1844-5, ) (SAH28). 23 'utterly' does not appear in the copy transcribed in the Clerk's Book. 24 Case Book ( ) (SAH261) entry for 26/10/ Norwich Mercury (10/01/1855).

7 And that appears to be that. I have been unable to trace any further mention of the case, either in the asylum records or the newspapers. The three discharged attendants do not appear to have been reinstated; they were speedily replaced, the replacements being in post by 8 November. Of the six attendants involved, only Fisher and Giles had served longer than 2 years; Wilkinson, Cook and Bell had served less than 18 months. Fisher had been in post since September 1846, for which he had received an extra five shillings a quarter. 26 The committee would have been loath to lose such an experienced attendant. The Newspapers 27 During the case, both the Norwich Mercury and the Daily News (London) raised questions as to the evidence presented and the conduct of both the Commission of Lunacy and the Committee of Visitors: 1. What kind of examination did Casson make on the first day (Wednesday morning)? A 'tumour' may well have been the result of some blow. In the light of this and Sizer's 'inability' to disclose the cause himself, why did Casson not more fully examine the chest and body or enquire of the attendants as to a possible cause? Despite visiting Sizer twice that day, Casson was unable to discover eight broken ribs and a broken breastbone (indeed, the broken breastbone was only discovered when both medical officers examined Sizer on Friday afternoon) The issue of the bedstead incident in September, although this was effectively dismissed as a potential cause of the injuries by both the commissioners and the medical officers. 3. The apparent lack of any exclamation from a patient who had sustained such serious injuries. The state of Sizer's mental well-being is completely ignored in the evidence. He appears to have made no communication at all during his last days, not even with his wife! 4. If there was sufficient suspicion to discharge certain attendants, there was sufficient evidence surely to justify a remand on a charge of manslaughter...if there was not, where is the justice which discharges them? The asylum records give the specific reasons why the attendants were summarily discharged (see above). Whether the evidence would have been able to satisfy the higher burden of proof in criminal proceedings is arguable (and possibly why the commissioners directed the committee to instruct counsel). A factor in the committee's decision must have been the issue of additional cost in pursuing a matter they considered closed. Although the 'reluctance ' to prosecute attendants who had been negligent or worse in their care of the patients extended to the 1880s even when it caused death. The committee then appeared more readily to deal with theft through the courts 'Is there no way of getting at the history of Sizer from the latter end of September to 18 October? If not, what value is the administration of the institution?' As we have seen, the Case Book for the 26 Wages Book ( ) (SAH75). As well as wages paid, the attendant index gives dates of service (although these details are not completed after 1869, for leaving service, and after 1873, for entering service). 27 Taken from the Norwich Mercury (18/11 and 02/12/1854) and the Daily News (London) (13/11/1854). 28 Casson was appointed medical superintendent upon Owen's retirement in However, he was compelled to resign shortly thereafter, 'having shown himself unfit to fulfil the duties of the office'. He committed suicide by taking prussic acid a few days later. Cherry p Annual Reports ( ) (SAH29). Attendants were discharged in 1880 for 'gross neglect of duty' for causing the death of two patients; the first when an epileptic suffocated due to lack of supervision, the second after scalding when placed in a bath that had not been checked for temperature. The next year, an attendant was discharged and prosecuted for stealing calico; they received a two week prison sentence.

8 period is wholly inadequate and the answer to this question must be no. That the Commissioners in Lunacy neglected to enforce their own rules regarding completion of the Case Book is 'regrettable'. 30 It should be noted that the previous resident medical officer, Dr Foote (see below), had implemented a system whereby each attendant was required to maintain a Daily Book in order to inform the medical officer of the 'various circumstances' as to the patients' well-being. There are no 'ward Daily Books' in the NRO; and none are mentioned in records contemporary to Sizer's case. Of course, the Case Book deficiencies were also incurred during Foote's period in office. 6. It remains to be seen whether the Commissioners in Lunacy will do their duty by endeavouring to discover the mystery. The last correspondence from the Commissioners in Lunacy (22 December 1854) appears to be more bark than bite; the commissioners could not enforce changes except by invoking the Secretary of State. 31 However, the commissioners did themselves have the authority to summon witnesses: 32 they could have summonsed Fisher themselves. 7. 'Persons who ought only to have charge of discipline' (eg the Superintendent) 'are placed above those who have charge of the medical treatment of the patients' (ie, medical officers). A point at the heart of Dr Foote's resignation in August and perhaps only settled by the appointment of a medical superintendent in However, perhaps the asylum management had 'learnt from their mistakes'. There is an entry on 29 November 1854 that Owen recorded that he had accompanied the night watch on his rounds and from then on this record was repeated quite regularly. Indeed, a schedule of when Owen visited the wards, whether by day or night, became part of his monthly report. Or maybe not. In their, admittedly generally positive, report, in June 1855, the Commissioners in Lunacy found that a patient had sustained a fractured collar bone during a fall in the garden during an epileptic fit - 'we regret to find that there is no record whatever of this occurrence either in the medical journal or Case Book. Nor do we think that bruises and minor accidents are duly registered by the medical officer'. This report is not included in the printed report for Foote Note A month after Sizer had entered the asylum, Dr Richard Foote had resigned as resident medical officer. Dr Foote had been in the post since February 1852 and was a 'zealous reformer'. 34 He, with G W W Firth was responsible for the first published medical officers' report in This document is comprehensive (78 pages). It gives not just what should be done but also the reasoning behind it. Deaths are recorded by person (anonymised) and, where applicable, post mortem remarks are recorded. Frustratingly, however, 'pharmaceutical measures adopted' had to be deferred owing to the report already occupying 'so much space'. Foote's resignation was the consequence of an absence of support from the Committee of Visitors 'and the want of any proper control over the attendants in the treatment of the patients'; ie, a difference of opinion between Foote and Owen exacerbated by Foote's dispute with the matron, who was Owen's wife! 36 In his defence of his achievements, Foote claimed to have transformed the asylum. 37 The 30 'Neglect to keep the Case Book (according to the form directed by the commissioners) shall for every neglect forfeit any sum not exceeding 10' (8 & 9 Vict c100 s60) (Lumley) 31 Cherry p81. " Eighth Report of the Commissioners in Lunacy to the Lord Chancellor, 1854, recorded that the Norwich Corporation had been reported 'since they persist in neglecting to make fit provision for their pauper lunatics' " & 9 Vict, c100 s100 (Lumley). 33 Reports of Commissioners in Lunacy ( ) (SAH141). 34 Cherry p Annual Report of the Medical Officers for 1853 (SAH28). 36 Cherry p78, Clerk's Letter Book ( ) (SAH38). 37 Norfolk Chronicle (18/08/1854).

9 'before' makes chilling reading, eg, diet was deficient in quantity and inferior in quality, the patients...with very few exceptions, complained of the cruelty used to them by the attendants, patients slept on straw mattresses which were often damp and less physically able patients were washed down with a mop, sometimes in the yard. Would the fate of William Sizer have been more positive under Dr Foote's care? Bibliography Norfolk Record Office SAH7: Minutes of the Committee of Visiting Magistrates ( ). SAH28: Annual Reports (1844-5, ) (Norwich Library also has a copy of the Annual Report for 1854). SAH29: Annual Reports ( ). SAH38: Clerk's Letter Book ( ). SAH75: Wages Book ( ). SAH129: Master's (Superintendent's) Journal and Report Book ( ). SAH138: Visiting Justices' Report Book ( ). SAH141: Reports of Commissioners in Lunacy ( ) (handwritten version of SAH28). SAH162: Visitors' Book ( ). SAH168/2: Reception Orders ( ). SAH175: Admission Register ( ). SAH221: Register of Discharges, Removals and Deaths (males) ( ). SAH232: Register of Burials ( ). SAH261: Case Book (Admissions No 3 - males) ( ). British Newspapers Archive (thanks to Norfolk Libraries) Norwich Mercury: 28/10/1854, 18/11/1854, 02/12/1854 and 10/01/1855. The inquest was also reported by, and documents sent to: the Norfolk Chronicle and the Norfolk News. The Mercury is the most comprehensive and, unless noted, the various reports are taken from this newspaper. The inquest was also reported, briefly in papers as geographically apart as the Bury and Norwich Post, the Daily News (London), the Cheshire Observer and the Leeds Mercury. The Daily News (London): 13/11/1854. Saunders' Newsletter: 10/06/1854. The Norfolk Chronicle: 18/08/ (thanks to Norfolk Libraries) In particular: baptismal, marriage records, Notice of Discharge, Census Records. Other Sources Blaxland, Gregory, The Middlesex Regiment (Duke of Cambridge's Own) (The 57th and 77th of foot), Leo Cooper Ltd., London ed Bucknill, John Charles, The Asylum Journal of Mental Science: Vol I: nos 1-14, pp 143-4, S Highley, London 1855 (thanks to the Internet Archive). Cherry, Steven, Mental Health Care in Modern England - The Norfolk Lunatic Asylum: St Andrew's Hospital , The Boydell Press Lumley, W G, The New Lunacy Acts, Shaw & Sons, London 1845 (thanks to the Internet Archive)

10 Skelly, A R, The Victiorian Army at Home, McGill University Press, Montreal 1977.